Aitkin Health Services

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure proper storage of open enteral feeding solutions and failed to date tube feeding supplies for 1 (R8) of 2 residents reviewed for tube feeding.Findings include:R8's annual Minimum Data Set (MDS) dated [DATE], indicated R8 was cognitively intact. Diagnoses included frontotemporal neurocognitive disorder, dysphagia, diabetes mellitus type 2, non-Alzheimer dementia, and anxiety disorder.R8's care plan revised 2/26/26, tube feeding care included:Bolus feeding.Change feeding solution container and syringe every 24 hours. Follow manufacturers' recommendations or per registered dietician regarding how long formula can be open.R8's provider orders dated 6/4/26, included:Change syringe and water container daily before breakfast.Please have dietician eval resident tube feeding needs and make recommendations.Jevity 1.2 Calorie Oral Liquid (Nutritional Supplements) Give 553 milliliters (mL) via gastrostomy tube (G-tube) three times a day…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to initiate orders and maintain documentation to ensure oxygen supplies were properly cleaned and maintained for 1 of 1 resident (R1) reviewed for respiratory care.Findings include:R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was severely cognitively impaired. Diagnoses included atrial fibrillation, heart failure, hypertension, pneumonia, non-Alzheimer's dementia.R1's care plan did not include oxygen use.R1's had a provider order dated 1/6/26, for oxygen 2 liters as needed (prn) to keep oxygen saturations above 90% and as needed for shortness of breath.R1's treatment administration record (TAR) reviewed on 6/2/26, included oxygen 2 liters prn to keep oxygen saturations above 90% as needed and for shortness of breath as needed, but had no instructions for cleaning, maintenance, or changing of oxygen tubing. TARs dated 3/2026, 4/2026, and 5/2026, also had no instructions for cleaning, maintenance, or changing of oxygen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and document review, the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC, Form CMS-10123) to 2 of 3 residents (R10, R37) reviewed whose Medicare Part A coverage ended and remained in the facility. Findings included: R10's Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage form (SNF ABN, CMS-10055), dated 3/10/25, identified on 3/13/25, estimated a daily rate of $515,44 would be charged and not covered by Medicare-A. R10's medical record lacked indication CMS-10123 was provided to the resident at least 48 hours prior to stoppage of Medicare part A. R10's census list dated 5/15/25, identified R10 remained a resident of the facility after 3/13/25, but not on Medicare part A as payer source. R37's Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage form (SNF ABN, CMS-10055), dated 11/25/24, identified on 11/28/24, an estimated daily rate of $500.00 would be charged and not covered by Medicare-A. R37's medical record lacked indication CMS-10123 was provided to the resident at least 48 hours prior to stoppage of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to ensure ordered as needed (PRN) antipsychotic medications were limited to a 14-day time period and a face-to-face provider visit with clinical documentation indicating the medication needed to remain was performed prior to the medication extended past the 14 day period. The facility also failed to document behaviors and non-pharmacological interventions utilized prior to usage of an antipsychotic for 1 of 5 (R39) residents reviewed for unnecessary medications. Findings include: R39's admission Minimum Data Set (MDS) assessment dated [DATE], identified R39 had significant cognitive impairment. Diagnoses included hypertension and dementia. Medications received included an antipsychotic. R39's active Order Summary Report dated 5/15/25, indicated Quetiapine Fumarate (an antipsychotic medication used for mental health behaviors) 25mg by mouth every 8 hours PRN for agitation, anxiety, or delusion was ordered on 4/17/25. The order lacked a 14 day stop date.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to enter and follow provider orders for 1 of 1 resident (R9) reviewed for provider orders. Findings included: R9's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R9 was cognitively intact and diagnoses included coronary artery disease, heart failure, and hypertension. Medications taken daily included a diuretic (water removing pill). R9's admission orders dated 4/17/25, indicated daily weights and to notify the provider for a 2-pound (lb.) weight gain in 24 hours or a 5 lb. weight gain in 7 days. R9's active Order Summary Report dated 5/13/25 lacked an order for daily weights or to call the provider based on weight gain parameters specified in the orders. During an interview on 5/13/25 at 1:18 p.m., nurse assistant (NA)-A stated all residents with daily weights were done by the NA and then given to the nurse to review. NA-A looked at her list and stated R9 was not a daily weight. During an interview 5/13/25 registered nurse (RN)-A…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to follow grievance policy and procedures involving 2 of 2 residents (R1, R2) when R1 voiced concerns about treatment received from another resident (R2) in the facility and a grievance was never filed on behalf of R1, and he was never provided resolution or follow up. Findings include: R1's admission Record indicated he admitted to the facility on [DATE]. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition. R1's care plan dated 4/10/25, indicated he was alert and oriented and was able to express his needs. R2's quarterly MDS dated [DATE], indicated a Brief Interview of Mental Status (BIMS) of 8 (moderate cognitive impairment), verbal behaviors directed toward others (threatening, screaming, cursing) 1-3 days. During interview on 4/29/25 at 4:21 p.m., R1 stated R2 intentionally antagonized him and said, I want it to stop. R1 said R2 approached him and and said things like, hit me, hit me. R1 stated he was not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to reduce the risk of falls for 1 of 3 residents (R3) reviewed for accidents and supervisor. R3 had a high risk for falls and was observed attempting to self-transfer from a wheelchair to bed. Findings include: During continuous observation on 3/19/25, R3 was seated in the dining room with his eyes closed at 6:45 a.m., where he remained until 7:47 a.m., when he propelled himself down the hall toward his room. Staff spoke with R3 on his way down the hall. At 7:51 a.m. R3 was observed propelling from his room. At 7:47 a.m. R3 told NA-B, I want to go to sleep but they keep kicking me out. NA-B said, they kicked you out, huh. then walked away. At 8:02 a.m. a staff member moved R3 to a table in the common area where he sat with a book. At 8:25 a.m. R3 remained seated in his wheelchair with his eyes closed. At 9:12 a.m. R3 again propelled himself toward his room. At 9:18 a.m., R3 got the door to his room open, and a housekeeper moved him back into…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and document review, the facility failed to notify the resident's physician timely with a change in condition for 1 of 3 residents (R1) when staff inserted an indwelling catheter three times, resulted in bleeding, blood clots, pain, discomfort, low urine output, and low blood pressure, sent to emergency room via ambulance, and developed sepsis, and admitted to intensive care unit. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified severely impaired cognition and no behaviors noted. MDS indicated R1 had an indwelling catheter, always incontinent of bowel, and neurogenic bladder (interference of the relationship between the nervous system and bladder function and affects the way bladder functions due to injury or disease). MDS also indicated R1 had impairment on one side of his upper and lower body and was dependent upon staff for all cares, transfers, and repositioning. R1's health conditions form dated 6/2/24, to 7/2/24, were identified as anemia, benign…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to report to the State Agency (SA) for 1 of 1 resident (R1) whose indwelling catheter was incorrectly placed three times resulting in bleeding, blood clots, pain, discomfort, low urine output, prolonged provider notification, sepsis, sent to emergency room via ambulance, and admitted to intensive care unit (ICU). Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified severely impaired cognition and no behaviors noted. R1 had an indwelling catheter and always incontinent of bowel. R1 had a neurogenic bladder (interference of the relationship between the nervous system and bladder function and affects the way bladder functions due to injury or disease). R 1 had impairment on one side of his upper and lower body and was dependent upon staff for all cares, transfers, and repositioning. R1's hospital admission notes dated 7/2/24, indicated indwelling catheter change completed at nursing home facility last evening resulted in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to thoroughly investigate and take steps to correct neglect of care for 1 of 1 resident (R1) who did not receive the necessary care and monitoring when facility staff inserted an indwelling catheter incorrectly three times, resulted in bleeding, blood clots, pain, discomfort, low urine output, prolonged provider notification, and low blood pressure, sent to emergency room via ambulance, and developed sepsis, and admitted to intensive care unit (ICU). Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified severely impaired cognition and no behaviors noted. R1 had an indwelling catheter and always incontinent of bowel. R1 had a neurogenic bladder (interference of the relationship between the nervous system and bladder function and affects the way bladder functions due to injury or disease). R 1 had impairment on one side of his upper and lower body and was dependent upon staff for all cares, transfers, and repositioning. R1's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure the resident or resident's representative was informed of the bed hold policy at the time of hospitalization for 1 of 3 residents (R1) reviewed for hospitalization. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified severely impaired cognition and no behaviors noted. R1 had an indwelling catheter and always incontinent of bowel. R1 had a neurogenic bladder (interference of the relationship between the nervous system and bladder function and affects the way your bladder function due to injury or disease). R1 had impairment on one side of his upper and lower body and was dependent upon staff for all cares, transfers, and repositioning. Review of R1's progress notes from 7/2/24, through 7/5/24, identified: - On 7/2/24, at 5:09 a.m. R1 screaming, reported a lot of pain rated 10 out of 10, blood pressure 90/53, bladder scanned 249 milliliters (ml), no urine in bag. On call provider notified and gave order to send to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to prevent future burns from hot beverages for 1 of 3 residents (R1), who spilled his coffee and noted to have redness on thigh and hand after staff utilized the microwave to reheat the cup of coffee. This had the potential to affect all residents residing in the facility who drank hot beverages. Findings include: R1's quarterly Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses which included dementia and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of facility report to the State Agency (SA) dated 4/3/24, indicated staff had placed a cup of coffee into the microwave to warm the coffee up. Staff brought the cup of coffee to R1 and the R1 spilt the coffee onto his lap. R1 was assessed for injuries by nursing staff and R1 was noted to have redness on his left thigh and left hand. Report indicated R1 drank coffee with every meal and no incidents previously. Further, report…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to review and update the plan of care for skin breakdown interventions for 1 of 2 residents (R17) reviewed for care planning. Findings include: R17's quarterly Minimum Data Set (MDS) dated [DATE], identified moderately intact cognition and diagnoses of right-sided hemiplegia (one-sided paralysis or weakness), hemiparesis (one-sided decrease in muscle strength), multiple sclerosis (MS an immune disorder affecting the nervous system), and ataxia (impaired coordination). R17 was at risk for pressure injury, had actual moisture associated skin damage (MASD), needed moderate assistance with rolling side to side, total assistance with toileting hygiene, and was always incontinent of bowel and bladder. Provider orders for R17 dated 2/14/24, identified nursing assistants (NA)s may apply barrier creams for skin care, skin checks by licensed nurses after bathing on Wednesdays, as well as daily skin checks during routine care. A care plan dated 2/26/24,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to comprehensively reassess and develop interventions to ensure appropriate care was provided to prevent pressure injuries for 1 of 1 resident (R17) reviewed who had a pattern of skin breakdown and was at risk for pressure ulcer formation. Findings include: R17's quarterly Minimum Data Set (MDS) dated [DATE], identified moderately intact cognition and diagnoses of right-sided hemiplegia (one-sided paralysis or weakness), hemiparesis (one-sided decrease in muscle strength), multiple sclerosis (MS an immune disorder affecting the nervous system), and ataxia (impaired coordination). R17 was at risk for pressure injury, had actual moisture associated skin damage (MASD), needed moderate assistance with rolling side to side, total assistance with toileting hygiene, and was always incontinent of bowel and bladder. Provider orders for R17 dated 2/14/24, identified nursing assistants (NA)s may apply barrier creams for skin care, skin checks by…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to monitor side effects of diuretic therapy and to act upon pharmacy recommendations for 1 of 5 residents (R16) reviewed for unnecessary medications. Findings include: R16's quarterly Minimum Data Set (MDS) dated [DATE], identified diagnoses of osteoporosis, chronic pain, hypertension, and atrial flutter (an abnormal heart rhythm). Provider orders for R16 dated 11/29/23, identified ibuprofen 200 milligrams (mg) take one tablet two times daily, vital signs every week on Tuesdays, amiloride (a diuretic medication) 5 mg take half tablet once daily, spironolactone (a diuretic medication) 100 mg take two tabs in the morning and one tab in the afternoon. R16's care plan dated 2/27/24, identified a problem statement for hypertension with interventions to monitor vital signs, update the provider with abnormal values, and observe for listed side effects of diuretics. The care plan also included a problem statement for pain related to effects of osteoporosis and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure as needed (PRN) psychotropic (mood altering) medication order was renewed beyond 14 days without an end date and to act upon pharmacy recommendations for 1 of 5 residents (R32) reviewed for unnecessary medications. Findings include: R32's quarterly Minimum Data Set (MDS) dated [DATE], identified severely impaired cognition and diagnoses of Alzheimer's dementia, dementia with severe behavioral disturbance and sleep disorder. R32 was dependent on staff for most activities of daily living (ADLs). R32's care plan dated 2/26/24, identified R32 took antianxiety medication related to behaviors. Interventions included medication administration, observing for side effects, making referrals for behaviors as needed, observing for changes in behavior and updating the provider. Provider orders for R32's identified the following: -8/7/23 Ativan (an anti-anxiety medication) 0.5 milligrams (mg) give one-half tab once daily on Monday and Fridays 30 minutes prior…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to develop a trauma informed care plan as well as establish mental health services in a timely manner for 1 of 3 residents (R2), which had the potential for psychosocial harm. Findings include: R2's quarterly minimal data set (MDS) dated [DATE], identified R2 had diagnoses which included multiple sclerosis, anxiety disorder and depression. R2's mood interview revealed R2 had moderate signs and symptoms of depression, including feeling down and thoughts of being better off dead or hurting self nearly every day. R2' Trauma-Informed Care assessment dated [DATE], revealed she had experienced mental, physical, and emotional abuse from past husbands and the most difficult time in R2's life was when her son and boyfriend died. R2 stated now I am sad all the time. Further, assessment indicated talking helps her when she is feeling anxious, angry, or sad and stated she did not have any support persons to help. R2 care plan dated [DATE], indicated R2 received…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure nonpharmacological interventions were care planned, attempted, and recorded before the administration of PRN (as needed) psychotropic medication for 1 of 3 residents (R3) who were reviewed. In addition, the facility failed to ensure residents prescribed psychotropic medications were monitored for target behaviors for 2 of 3 residents (R2, R3) reviewed. Findings include: R3's admission Minimal Data Set (MDS) dated [DATE], indicated R1 had a diagnosis of anxiety and was cognitively intact. R3 did not exhibit any behaviors. R3's medication administration record dated March 2023, indicated R3 could utilize alprazolam (Xanax) 0.25 milligram PRN after scheduled nighttime dose and before 3:00 a.m., which R3 received 17 times in March. R3's record lacked evidence of non-pharmacological interventions attempted prior to administering PRN medication. R3's Psychoactive Medication Informed Consent Form dated 2/9/23, revealed R3 had an order for Xanax and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure coordination of care upon discharge from the hospital for 1 of 3 residents (R1) reviewed for change in condition. In addition, the facility failed to monitor a newly identified bruise for 1 of 3 residents (R1) reviewed. Findings include: R1's significant change minimal data set (MDS) dated [DATE], indicated R1 had diagnoses of dementia, anxiety and severe cognitive impairment. R1's care plan printed 12/19/23, identified R1 required assistance with activities of daily living (ADLs) such as dressing, toileting, grooming, transferring, and ambulating. R1's Emergency Department (ED) Provider Notes dated 11/26/23, revealed R1 was noted to have a closed fracture of multiple pubic rami with no restrictions, course of action recommended was weight bear as tolerated with walker. Further review of ED note indicated R1 had a urinalysis completed, which did not reveal any concern for a urinary tract infection (UTI). At the time of discharge from the ED,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure appropriate personal protective equipment (PPE) was worn for 1 of 2 residents (R1) reviewed who was diagnosed with Coronavirus disease (COVID)-19. In addition, the facility failed to ensure visitors were educated on appropriate PPE while visiting a resident who was positive for COVID-19. Findings include: R1's significant change minimal data set (MDS) dated [DATE], indicated R1 had diagnoses of dementia, anxiety and had severe cognitive impairment. R1's care plan printed 12/19/23, identified R1 required assistance with activities of daily living (ADLs) such as dressing, toileting, grooming, transferring, and ambulating. Review of untitled document dated 12/15/23, identified a rapid swab was performed on R1 and returned with a positive COVID-19 result. R1 was immediately placed on isolation precautions per CDC regulations. Resident had staff that wear PPE for airborne precautions and don/doff PPE (gown, gloves, face shield, N95…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to report a serious bodily injury within two hours, as required, to the State Agency (SA) for 1 of 3 residents (R2), who sustained fractured ribs following a fall. Findings include: R2's annual Minimal Data Set (MDS) dated [DATE], identified R2 had diagnosis of Alzheimer's disease and severely impaired cognition. R2's MDS identified R2 required extensive assistance of one staff for activities of daily living such as bed mobility, transfers, dressing and toileting. MDS revealed R2 has had two or more falls with no injury since prior MDS assessment. R2's Fall Scene Investigation dated 4/20/23, indicated R2 had an unwitnessed fall in her room and was found on the floor in a sitting position and at the time of the fall R2 was assessed by licensed practical nurse (LPN)-A, who determined there were no injuries or concerns at that time. Further, Fall Scene Investigation revealed on 4/21/23, R2 was brought to Urgent Care to be evaluated and x-rays revealed that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and document review, the facility failed analysis root cause for falls for 1 of 3 (R3), implement interventions determined by the interdisciplinary team (IDT) to prevent future falls for 2 of 3 residents (R1, R2) and revise care plans with updated fall interventions for 3 of 3 residents (R1,R2, R3) reviewed for falls. Findings include: R1's admission Minimal Data Set (MDS) dated [DATE], identified R1 had diagnosis of dementia and severely impaired cognition. R1's MDS identified R1 required extensive assistance by two staff members for activities of daily living (ADLs) such as bed mobility, transfers, dressing and toileting. MDS revealed R1 had two or more falls with no injury since admission. R1's Fall Scene Investigation dated 8/12/23, revealed IDT reviewed R1's fall and new intervention was added to have staff turn on favorite radio station when R3 was in bed due to R3 enjoying country music and finds music soothing. However, R3's care plan lacked evidence of being revised to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.